Bell’s palsy, Ramsay Hunt Syndrome and Hearing Loss

Bell’s palsy is a sudden or rapid onset facial paralysis or weakness which develops over hours to a day or two. If the face takes longer than 2-3 days to become paralyzed, the disorder is probably not Bell’s palsy and other causes need to be considered. Bells’ palsy is a viral neuritis or viral inflammation of the nerve that makes the face to smile.

This is a peripheral palsy of the facial nerve that results in muscle weakness on one side of the face. Most patients affected with this paralysis develop unilateral facial paralysis over one to three days with forehead involvement and no other neurologic abnormalities.

Symptoms of Bell’s palsy typically show up in the first week and then gradually resolve over three weeks to three months. It’s more common in patients who are diabetic, and it can affect people of any age, anytime. Majority of people who are affected by this paralysis are in their 40s.

Symptoms of Bell’s palsy related to the ear:

  • Ear & facial pain.
  • Numbness in front of the ear.
  • Ringing sound in the ear.
  • Vertigo
  • Hearing Loss.

Sometimes, facial nerve palsies from acute and chronic otitis media have a more gradual onset, with accompanying ear pain and fever. This is also known as the Ramsay Hunt Syndrome, where the patients develop a pronounced prodrome of pain to the vesicular eruption in the ear canal and pharynx, although cases without the vesicular eruption have been reported, it more often affects both facial nerves. Tumors will present with a more insidious onset of symptoms over weeks or months.

Other associated symptoms include dry eye, eye irritation, and blurry vision, taste disturbance, vague numbness just in front of the ear, ringing in the ear, some dizziness or vertigo, and relatively rarely hearing loss. Quite similar to Bell’s palsy, the facial paralysis onset is rapid, but it is typically preceded by painful blisters on the outer ear or on the ear canal back wall.

Symptoms of Ramsay Hunt syndrome related to the ear:

  • Ear rashes.
  • Ear Pain.
  • Hearing Loss
  • Tinnitus
  • Vertigo

Pain with Ramsay Hunt syndrome is typical of shingles and may precede the paralysis by up to a week and rarely occurs without blisters. Untreated, the prognosis of Ramsay Hunt syndrome is much worse than for Bell’s palsy with well over 50% suffering from permanent residual weakness and some having a permanently complete paralysis on one side of the face. Aggressive, early treatment lowers the bad outcome risk.

In the case of the facial nerve, an additional factor is the bony channel which it runs through to get to the face. As the facial nerve exits the brainstem, it is adjacent to the hearing and balance nerve as well as one of the taste nerves, the nervus intermedius. The latter is also the nerve which controls nose moisture and formation of tears for the eye. Where these nerves are together in the internal ear canal, they float in cerebrospinal fluid.

 At the lateral end of the internal ear canal, the hearing and balance nerves enter the inner ear, but the facial nerve and the nervus intermedius join together to course just above the inner ear. At this location, there are at least two nerve junctions and cell body or ganglion areas. The one considered most likely the source of critical swelling is the ganglion of the meatal foramen.

 In this region of the facial nerve, a leathery brain covering wraps the nerve pretty tightly to prevent spinal fluid from leaking out along the nerve. The tightly wrapped nerve then enters the bony nerve canal which is barely large enough for a not-swollen nerve. Anatomic research suggests that the tighter this bony canal is, the less it allows a nerve to swell without compromising its function.


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